Health and the Millennium Development Goals

20002005 keep the promise

2015

WHO Library Cataloguing-in-Publication Data

World Health Organization.Health and the Millennium Development Goals.

1.World health 2.Health priorities 3.Delivery of health care 4.Cost of illness 5.Development 6.Goals 7.Social justice I.Title

ISBN 92 4 156298 6 (NLM classification: WA 530.1)

© World Health Organization 2005

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Photos credits: WHO/P. Virot - WHO/TBP/Davenport, Falise, Hampton, Van der Hombergh, Colors magazine/J. Langvad -International Labour Organization/Crozet M., Deloche P., Derrien J.M., Lissac P., Maillard J.

Acknowledgements

This report is a joint production of the Department of MDGs, Health and Development Policy (HDP) and theDepartment of Measurement and Health Information Systems (MHI). Rebecca Dodd served as managing editor, andcontributions were provided by: Michel Thieren and Michel Beusenberg (Chapter 1); Andrew Cassels (Chapter 2);Rebecca Dodd (Chapters 3, 5 and 6); Kenji Shibuya and Colin Mathers (Chapter 4); and Carla Abou-Zahr and MichelThieren (Chapter 7).

Overall guidance was provided by Carla Abou-Zahr, Michel Beusenberg, Ties Boerma and Andrew Cassels, andadditional advice and comments were gratefully received from Denis Daumerie, Cecil Haverkamp, Amine Kébé,Brenda Killen, Dermot Maher, Paolo Piva, Heide Richter-Airijoki, Jacqueline Toupin, Phyllida Travis, Eugenio Villarand Diana Weil. Thanks are also due to the many WHO regional offices and departments who contributed text,comments and ideas, and to Catherine Browne and Marie-Claude van Holten, who provided administrative support.

MDGs, Health and Development Policy World Health Organization • Avenue Appia 20 • 1211 Geneva 27 • SwitzerlandEmail: HDPMDGNews@who.intwww.who.int/mdgwww.who.int/hdp

ISBN 92 4 156298 6

Foreword

The eight Millennium Development Goals represent a unique globalcompact. Derived from the Millennium Declaration, which was signed by 189 countries, the MDGs benefit from international political support. As such, they reflect an unprecedented commitment by the world’s leadersto tackle the most basic forms of injustice and inequality in our world:poverty, illiteracy and ill-health.

The health-related MDGs do not cover all the health issues that matter topoor people and poor countries. But they do serve as markers of the mostbasic challenges ahead: to stop women dying during pregnancy and childbirth; to protect young children from ill-health and death; and to tackle themajor communicable diseases, in particular HIV/AIDS. Unless we can dealwith these fundamental issues, what hope is there for us to succeed inother, equally important areas of health?

2005 is a critical year, with the MDG target date of 2015 only 10 yearsaway. The evidence so far suggests that while there has been some progress,too many countries - particularly the poorest - are falling behind in health.This is likely to affect other areas, including education, gender equality and poverty reduction. In short, the MDG vision - to create a better andfairer world - will fail unless we can do more to improve the health of poor people.

This report explains some of the reasons for the slow progress, and suggestssolutions. It looks beyond the statistics to discuss strategic and policy areaswhere change is needed and support should be provided. As such, it summarizes WHO’s contribution to debates on the MDGs and to the 2005 World Summit in September.

Much faster progress in health is possible and we have many success storiesto draw on. We have the knowledge and tools, and the resources areattainable. What is required is political will and commitment to dramaticallyscale up our efforts. If we are to succeed, we must start now. Fewchallenges are more profound, or more urgent.

LEE Jong-wookDirector-GeneralWorld Health Organization

3

Table of Contents

07 Introduction

‘0112 Progress towards the health MDGs15 Goal 1 : Eradicate extreme poverty and hunger16 Goal 4 : Reduce child mortality18 Goal 5 : Improve maternal health20 Goal 6 : Combat HIV/AIDS and other diseases26 Goal 7 : Ensure environmental sustainability29 Goal 8 : Develop a global partnership for development

‘0230 Fully functioning and equitable health systems:

a prerequisite for reaching the health MDGs33 A health systems action agenda34 Human resources for health36 Fair and sustainable financing36 Drugs, diagnostics and the basic infrastructure needed to deliver services37 Assessing progress and tracking results38 Organizing health services towards a more equitable and pro-poor approach40 Defining the rules of engagement: stewardship and the role of the state41 Conclusion

‘0342 Moving beyond health service delivery: health in development45 Health and development: what does it mean in practice?46 Raising the profile of health in national development processes48 Programme-based approaches49 Conclusion

‘0450 Addressing the changing health challenges of the developing world52 Widening health gaps53 Increasingly complex burden of disease57 The impact of globalization59 Conclusion

‘0560 Mobilizing resources63 Goal 863 What will it cost to achieve the health MDGs?64 The economic impact of scaling-up65 Conclusion

‘0666 Improving the effectiveness of aid for health68 Ownership, harmonization, alignment, and results70 The case of health: an increasingly complex sector70 Development cooperation in fragile states73 Conclusion

‘0774 Challenges in tracking progress and measuring achievements76 Policy challenges76 Technical challenges79 Operational challenges80 Health Metrics Network81 Conclusion

82 List of acronyms

Health and the Millennium Development Goals

and the Millennium Development Goals in 2005 Health

and the Millennium Development Goals in 2005Health

La santé et les objectifs du Millénaire pour le développement

l d l b d llo del Milenio

and the Millennium Development Goals in 2005 Health

20002005 keep the promise

2015

7

Introduction

2000, the global community made an historic commitment: to eradicate extreme poverty and improve the health and welfare of the world’s poorestpeople within 15 years. The commitment was set forth in the MillenniumDeclaration (1) and derived from it are eight time-bound goals, known as the Millennium Development Goals (MDGs, see chart).

The MDGs have gained widespread acceptance in rich and poor countries alike. They are seen to provide an overarching framework for developmentefforts, and benchmarks against which to judge success. With the MDG target date of 2015 just 10 years away, now is the time to review progress, take stock of achievements, and address challenges. From the perspective ofhealth, the MDGs are important in at least five ways.

First, the MDGs provide a common set of priorities for addressing poverty. Thisunprecedented level of agreement between national governments, internationalagencies, and the United Nations system brings both political momentum andfocus to development efforts.

Second, health is at the heart of the MDGs - a recognition that health is centralto the global agenda of reducing poverty as well as an important measure ofhuman well-being. Health is represented in three of the eight goals, and makesan acknowledged contribution to the achievement of all the other goals, inparticular those related to the eradication of extreme poverty and hunger,education, and gender equality. Importantly, the health goals also focus onproblems which disproportionally affect the poor.

Third, the MDGs set quantifiable and ambitious targets against which tomeasure progress. These provide an indication of whether efforts are on track,and a means of holding decision-makers to account.

Fourth, it is possible to calculate what it would cost to achieve the MDGs. This in turn draws attention to the massive funding gap between available and needed resources, thus providing additional support to long-standing calls from the health sector that funding needs to be dramatically increased.

Fifth, goal 8 calls for a global partnership for development. This unique featureof the MDGs recognizes that there are certain actions rich countries must take ifpoor countries are to achieve goals 1 to 7. Goal 8 is a reminder that globalsecurity and prosperity depend on a more equitable world for all.

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Importantly, the MDGs have also helped to crystallize the challenges in health.As developed and developing countries begin to look seriously at what it would take to achieve the health MDGs, the bottlenecks to progress havebecome clearer. These challenges - again, we have identified five - are the subject of this report. They also represent core elements of WHO’s strategyfor achieving the goals.

The first challenge is to strengthen health systems. Without more efficient andequitable health systems, countries will not be able to scale up the diseaseprevention and control programmes required to meet the specific health goals ofreducing child and maternal mortality and rolling back HIV/AIDS, TB, andmalaria. Chapter 2 outlines an agenda of action to improve health systems andto make them more responsive to the needs of the poor.

The second challenge is to ensure that health is prioritized within overalldevelopment and economic policies. This means looking beyond the healthsystem and addressing the broad determinants of ill-health - low levels ofeducation, poverty, unequal gender relations, high risk behaviours, and anunhealthy environment - as well as raising the profile of health within nationalpoverty reduction and government reform processes. Chapter 3 looks at thepractical implications of addressing health within the context of povertyreduction, and makes the point that within the group of developing countriesthere are very different experiences and needs. Fragile states, and thoseemerging from conflict, require particular attention.

The third challenge is to develop health strategies that respond to the diverseand evolving needs of countries. This means designing cost-effective strategieswhich address those diseases and conditions which account for the greatestshare of the burden of disease, now and in the future. In addition to thepriorities reflected in the MDGs, reproductive health interventions will beessential in all countries. Efforts to reduce violence and injuries - as well asnoncommunicable diseases such as those related to cardiovascular disease andtobacco use - are important almost everywhere. As discussed in Chapter 4, theMDGs indicate desirable outcomes in terms of overall improvements in humanwell-being. The means of reaching those outcomes will necessarily encompass a broad range of activities - including a wide range of health actions.

The fourth challenge is to mobilize more resources for health in poor countries.Currently, low-income countries cannot ‘afford’ to achieve the MDGs, and aid isnot filling the gap. Chapter 5 looks at how much it would cost to achieve thehealth MDGs, while Chapter 6 examines how aid (development assistance) forhealth could be delivered more efficiently and equitably.

The fifth challenge is that we need to improve the quality of health data.Measuring country progress towards the MDGs is a key responsibility of nationalgovernments, and global monitoring is one of the most important functionsperformed by the United Nations system. Such monitoring is instrumental in

and the Millennium Development Goals in 2005 Health

and the Millennium Development Goals in 2005Health

La santé et les objectifs du Millénaire pour le développement

l d l b d llo del Milenio

and the Millennium Development Goals in 2005 Health

informing global and national policy-making. At the global level, demonstratingprogress can help to generate further resources and sustain political momentum.At country level, reliable information can help to ensure that policies are correctlyoriented, and targeted at those most in need. Problems include paucity of data,weaknesses in health information systems, over-analysis of data, and the challenge of generating disaggregated information which is needed to look atdifferences between men and women, rich and poor. Chapter 7 examines someof the difficulties involved in monitoring the MDGs, and suggests some solutions.By examining these five challenges, this report focuses on policy issues ofrelevance to the health sector as a whole. Accordingly, it does not focus on anyparticular technical area, nor look at progress towards the MDGs on a country-

by-country basis. However, Chapter 1 does provide aglobal overview of progress towards the health

MDGs to date, identifying areas where therehas been success, and many others where

progress has been slower than hoped.…

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Tackling diseases and conditions which disproportionately affect the poor iscentral to WHO’s work. Efforts to achieve the MDGs are thus part of WHO’s corebusiness. WHO has extensive programmes to assist countries in their efforts to tackle HIV/AIDS, TB, and malaria; improve child and maternal health andnutrition; and scale up access to essential medicines. As a reflection of this,WHO’s commitment to the Millennium Declaration has been reaffirmed by itsgoverning bodies (2, 3) and WHO’s next General Programme of Work will coverthe period 2006 to 2015 - a time frame that was chosen specifically tocorrespond to the MDG target date of 2015. So while the MDGs do not reflectthe entirety of WHO’s work, they are central to its agenda in assisting MemberStates, and represent important milestones against which the Organization’soverall contribution to health development can be measured.

Governments of rich and poor countries, development organizations, and civilsociety groups look to WHO for leadership and guidance in achieving the healthMDGs. This report lays out the essential elements - the strategies and inputs -that will help the international community, working collectively, to tackle thehealth crisis facing many poor countries and, in so doing, contribute to povertyreduction.

The issues covered in this report were identified at a WHO interregional meetingheld in Costa Rica in November 2004. Representatives from all six WHO regions,along with staff from headquarters and some country offices, came together todiscuss the key, overarching challenges to achieving the MDGs. The result was apaper prepared for the Executive Board and a resolution approved by the Fifty-eighth World Health Assembly in May 2005 (4, 5). Both documents set forthwhat WHO believes to be the core strategic directions for achieving the healthMDGs. This report goes into detail, reflecting more fully the wealth and depth ofthe discussions in Costa Rica.

1 - United Nations Millennium Declaration. New York, NY, United Nations, 2000 (A/RES/55/2; http://www.un-ngls.org/MDG/A-RES-55-2.pdf, accessed 22 April 2005).

2 - Resolution EB109.R3. WHO’s contribution to achievement of the development goals of the United Nations Millennium Declaration. In: 109th Session of the Executive Board, Geneva, 14-21 January 2002. Resolutions and decisions. Geneva, World Health Organization, 2002 (EB109.R3; http://www.who.int/gb/ebwha/pdf_files/EB109/eeb109r3.pdf, accessed 22 April 2005).

3 - WHO’s contribution to achievement of the development goals of the United Nations Millennium Declaration. Note by the Director-General. In: Fifty-fifth World Health Assembly, Geneva, 13-18 May 2002. Geneva, World Health Organization, 2002 (A55/6; http://www.who.int/gb/ebwha/pdf_files/WHA55/ea556.pdf, accessed 22 April 2005).

4 - Achievement of the health-related Millennium Development Goals. Report by the Secretariat. In: 115th Session of the Executive Board, Geneva, 17-25 January 2005. Geneva, World Health Organization, 2005. (EB115/5;http://www.who.int/gb/ebwha/pdf_files/EB115/B115_5-en.pdf, accessed 1 June 2005).

5 - Resolution WHA58.30. Accelerating the achievement of the internationally agreed health-related development goals includingthose contained in the Millennium Declaration. In: Fifty-eighth World Health Assembly, Geneva, 16-25 May 2005. Geneva, WorldHealth Organization, 2005 (WHA58.30; http://www.who.int/gb/ebwha/pdf_files/WHA58/WHA58_30-en.pdf, accessed 1 June 2005).

and the Millennium Development Goals in 2005 Health

and the Millennium Development Goals in 2005Health

La santé et les objectifs du Millénaire pour le développement

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11

Goal 1: Eradicate extreme poverty and hungerTarget 1 Halve, between 1990 and 2015, the proportion of people whose income is less than one dollar a day

Target 2 Halve, between 1990 and2015, the proportion of peoplewho suffer from hunger

4. Prevalence of underweight children under five years of age 5. Proportion of population below minimum level of dietary energy

consumption

Goal 2: Achieve universal primary educationTarget 3 Ensure that, by 2015, children everywhere, boys and girls alike, will be able to complete a full

course of primary schooling

Goal 3: Promote gender equality and empower womenTarget 4 Eliminate gender disparity in primary and secondary education, preferably by 2005, and at all

levels of education no later than 2015

Goal 4: Reduce child mortalityTarget 5 Reduce by two-thirds, between

1990 and 2015, the under-fivemortality rate

13. Under-five mortality rate14. Infant mortality rate15. Proportion of one-year-old children immunized against measles

Goal 5: Improve maternal healthTarget 6 Reduce by three-quarters,

between 1990 and 2015, thematernal mortality ratio

16. Maternal mortality ratio17. Proportion of births attended by skilled health personnel

Goal 6: Combat HIV/AIDS, malaria and other diseasesTarget 7 Have halted by 2015 and

begun to reverse the spread ofHIV/AIDS

Target 8 Have halted by 2015 andbegun to reverse the incidenceof malaria and other majordiseases

18. HIV prevalence among pregnant women aged 15-24 years19. Condom use rate of the contraceptive prevalence rate20. Ratio of school attendance of orphans to school attendance

of non-orphans aged 10-14 years

21. Prevalence and death rates associated with malaria22. Proportion of population in malaria-risk areas using effective

malaria prevention and treatment measures23. Prevalence and death rates associated with tuberculosis24. Proportion of tuberculosis cases detected and cured under

DOTS (Directly Observed Treatment Short-course)

Goal 7: Ensure environmental sustainabilityTarget 9 Integrate the principles of

sustainable development intocountry policies and programmesand reverse the loss ofenvironmental resources

29. Proportion of population using solid fuels

Target 10 Halve by 2015 the proportion ofpeople without sustainable accessto safe drinking-water and sanitation

Target 11 By 2020 to have achieved asignificant improvement in thelives of at least 100 million slumdwellers

30. Proportion of population with sustainable access to animproved water source, urban and rural

31. Proportion of population with access to improved sanitation,urban and rural

Goal 8: Develop a global partnership for developmentTarget 12 Develop further an open, rule-based, predictable, non-discriminatory trading and financial systemTarget 13 Address the special needs of the least developed countriesTarget 14 Address the special needs of landlocked countries and small island developing statesTarget 15 Deal comprehensively with the debt problems of developing countries through national and

international measures in order to make debt sustainable in the long termTarget 16 In cooperation with developing countries, develop and implement strategies for decent and

productive work for youth

Target 17 In cooperation withpharmaceutical companies,provide access to affordableessential drugs in developingcountries

46. Proportion of population with access to affordable essentialdrugs on a sustainable basis

Target 18 In cooperation with the private sector, make available the benefits of new technologies, especiallyinformation and communications

Health Targets Health Indicators

Sources: “Implementation of the United Nations Millennium Declaration”, Report of the Secretary-General, A/57/270 (31 July 2002), firstannual report based on the ”Road map towards the implementation of the United Nations Millennium Declaration”, Report of theSecretary-General, A/56/326 (6 September 2001); United Nations Statistics Division, Millennium Indicators Database, verified in July 2004;World Health Organization, Department of MDGs, Health and Development Policy (HDP).

Health in the Millennium Development Goals

and the Millennium Development Goals in 2005 Health

and the Millennium Development Goals in 2005Health

La santé et les objectifs du Millénaire pour le développement

and the Millennium Development Goals in 2005 Health